Every finding on record at Lakeview Christian Home Health

A Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Mexico Department of Health. An unannounced on-site Recertification Survey at the above-named Home Health Agency (HHA) from 01/09/23 to 01/11/23 resulted in the following findings respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on the emergency preparedness (EP) plan review and interview, the home health agency (HHA) failed to maintain a comprehensive emergency preparedness program that meets the requirements of the federal regulations. The deficient practice had the potential to affect the current 60 HHA patients, the current 17 HHA staff members, any future patient admitted to the agency for home health services, and any future employee hired by the agency when the EP plan had to be activated. 1. The HHA failed to ensure a facility-based and community-based risk assessment, utilizing an all-hazards approach, had been reviewed and updated since 2017. (See findings in tag E0006) 2. The HHA failed to ensure the EP plan included the patient population and the type of services the HHA had the ability to provide in an emergency. (See findings in tag E0007) 3. The HHA failed to ensure the EP included its plan for cooperating and collaborating with local, regional, State, and Federal emergency preparedness officials in order to maintain an integrated response during a disaster or emergency situation. (See findings in tag E0009) 4. The HHA failed to ensure the EP included contact information for the State and Federal emergency management agencies. (See findings in tag E0031) 5. The HHA failed to ensure the communication plan included the manner in which the HHA would provide information about the HHA's occupancy and needs to the authority having jurisdiction during an emergency. (See findings in tag E0034) 6. The HHA failed to provide documentation that the agency staff had received emergency preparedness training at least every two years. (See findings in tag E0037)

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on the emergency preparedness (EP) plan review and interview, the home health agency (HHA) failed to ensure a facility-based and community-based risk assessment, utilizing an all-hazards approach, had been reviewed and updated since 2017. The deficient practice had the potential to affect the current 60 HHA patients, the current 17 HHA staff members, any future patient admitted to the agency for home health services, and any future employee hired by the agency when the EP plan had to be activated. Review of the "Emergency Preparedness Plan 2019," that was presented when a request was made to review the HHA's EP plan, indicated the "Risk Vulnerability Analysis" was dated 11/28/17. Review of the "Disaster and Emergency Plan for [name of HHA] 2/19/2022 [02/19/22]," presented after the original request was received, indicated the plan did not have an updated risk vulnerability analysis. In an interview on 01/09/23 at 3:50 PM, Assistant Director of Nursing (ADON) stated he/she did not have an updated risk vulnerability analysis to present. ADON confirmed the analysis had not been updated since 11/28/17.

EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: Based on the emergency preparedness (EP) plan review and interview, the home health agency (HHA) failed to ensure the EP plan addressed the patient population and the type of services the HHA could provide during an emergency. The deficient practice had the potential to affect the current 60 HHA patients, the current 17 HHA staff members, any future patient admitted to the agency for home health services, and any future employee hired by the agency when the EP plan had to be activated. Review of the "Emergency Preparedness Plan 2019," that was presented when a request was made to review the HHA's EP plan, indicated the "Patient Population Analysis for Home Health Agencies" was for 2018 and dated "3Q/2017" [third quarter 2017]. Review of the "Disaster and Emergency Plan for [name of HHA] Updated 2/19/2022 [02/19/22]," presented after the original request was received, indicated the plan did not have an updated analysis of the patient population and the type of services the agency would be able to provide in an emergency. In an interview on 01/09/23 at 3:50 PM, Assistant Director of Nursing (ADON) stated he/she did not have an updated analysis of the patient population and the type of services the agency would be able to provide in an emergency to present. ADON confirmed the analysis had not been updated since 2017.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on the emergency preparedness (EP) plan review and interview, the home health agency (HHA) failed to ensure the EP included its plan for cooperating and collaborating with local, regional, State, and Federal emergency preparedness officials in order to maintain an integrated response during a disaster or emergency situation. The deficient practice had the potential to affect the current 60 HHA patients, the current 17 HHA staff members, any future patient admitted to the agency for home health services, and any future employee hired by the agency when the EP plan had to be activated. Review of the "Disaster and Emergency Plan for [name of HHA] Updated 2/19/2022 [02/19/22]" included no documentation of the agency's plan for cooperating and collaborating with local, regional, State, and Federal emergency preparedness officials during a disaster or emergency. In an interview on 01/09/23 at 3:50 PM, Assistant Director of Nursing (ADON) confirmed the agency's EP plan did not include a plan for cooperating and collaborating with local, regional, State, and Federal emergency preparedness officials during a disaster or emergency.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on the emergency preparedness (EP) plan review and interview, the home health agency (HHA) failed to ensure the EP included contact information for the State and Federal emergency management agencies. The deficient practice had the potential to affect the current 60 HHA patients, the current 17 HHA staff members, any future patient admitted to the agency for home health services, and any future employee hired by the agency when the EP plan had to be activated. Review of the "Disaster and Emergency Plan for [name of HHA] Updated 2/19/2022 [02/19/22]" included no documentation of the contact information for the State and Federal emergency management agencies. In an interview on 01/09/23 at 3:50 PM, Assistant Director of Nursing (ADON) confirmed the agency's EP plan did not include the contact information for the State and Federal emergency management agencies.

Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This STANDARD is not met as evidenced by: Based on the emergency preparedness (EP) plan review and interview, the home health agency (HHA) failed to ensure the communication plan included the manner in which the HHA would provide information about the HHA's occupancy and needs to the authority having jurisdiction during an emergency. The deficient practice had the potential to affect the current 60 HHA patients, the current 17 HHA staff members, any future patient admitted to the agency for home health services, and any future employee hired by the agency when the EP plan had to be activated. Review of the "Disaster and Emergency Plan for [name of HHA] Updated 2/19/2022 [02/19/22]" included no documentation of the manner in which the HHA would provide information about the HHA's occupancy and needs to the authority having jurisdiction during an emergency. In an interview on 01/09/23 at 3:50 PM, Assistant Director of Nursing (ADON) confirmed the agency's EP plan did not include the manner in which the HHA would provide information about the HHA's occupancy and needs to the authority having jurisdiction during an emergency.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on the emergency preparedness (EP) plan review and interview, the home health agency (HHA) failed to provide documentation that the agency staff had received emergency preparedness training at least every two years. The deficient practice had the potential to affect the current 60 HHA patients, the current 17 HHA staff members, any future patient admitted to the agency for home health services, and any future employee hired by the agency when the EP plan had to be activated. No documentation of emergency preparedness training of the HHA staff was presented to the surveyor as of the conclusion of the survey on 01/11/23 at 10:30 AM. In an interview on 01/09/23 at 3:50 PM, Assistant Director of Nursing (ADON) stated he/she would have to check for documentation of the staff's training on emergency preparedness. ADON did not return with documentation of staff training on emergency preparedness by the conclusion of the survey.

A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of New Mexico Department of Health. An unannounced on-site Recertification Survey conducted at the above-named Home Health Agency (HHA) facility from 01/09/23 to 01/11/23 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under 42 CFR 484, Subparts A through C with the following standard-level deficiencies listed below. The agency census was 60.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on patient medical record reviews, policy reviews, and interviews, the home health agency (HHA) failed to ensure patients initial assessment was conducted within 48 hours of the date the referral was received or within 48 hours from the time the patient returned from the hospital for two patients (Patient (P) 4, P7) of seven patient records reviewed. This deficient practice had the potential to affect any future patient admitted for home health services. Review of the agency policy titled, "Initial Assessments/Comprehensive Assessments," revised March 2018, indicated ". . . Initial Assessment and Time frame: A RN, PT, or SLP must conduct the initial assessment visit within 48 hours of referral, within 48 hours of the patient's return home or on the physician-ordered start of care date. . ." 1. Review of P4's electronic medical record (EMR) under the "Order" tab indicated the "DME [durable medical equipment]/Oxygen/Resp [respiratory] Home Health Order" was signed by the physician on 11/29/22. Review of P4's "Referral Form" under the "Misc." tab in the EMR and signed by Director on 11/30/26 indicated "Date to be admitted 12-06-22 (per spouse's request)." Review of P4's "Home Health Certification and Plan of Care" under the "Misc." tab in the EMR for the certification period of 12/06/22 to 02/03/23 indicated P4's start of care (SOC) date was 12/06/22, seven days after the order from the physician. There was no documentation in P4's EMR that P4's physician was notified of the spouse's request and that another order was obtained approving the change in the plan of care (POC) that was ordered. In an interview on 01/10/23 at 12:00 PM, DON stated he/she did not see documentation that P4's physician was notified of the delay in the SOC.DON confirmed there was no documentation that the physician of a physician's order approving the change in P4's SOC date. 2. Review of P7's EMR indicated an "Order Form" under the "Orders" tab signed by the physician on 11/23/22 for ". . . Home health Nursing and Therapy to Evaluate and treat as indicated." Review of P7's "Home Health Certification and Plan of Care" under the "Orders" tab for the certification period of 11/28/22 to 01/26/23 indicated P7's SOC date was 11/28/22, five days after the referral was received by fax. In an interview on 01/10/23 at 12:27 PM, DON confirmed the patient was not admitted within 48 hours of receipt of the referral.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on patient medical record reviews, policy reviews, and interviews, the home health agency (HHA) failed to ensure services were provided only as ordered by the physician for two (Patient (P) 3, P4) of seven patient records reviewed. This deficient practice had the potential to affect the current 60 patients receiving services from the HHA and any future patient admitted for home health services. Review of the agency policy titled, "Plan of Care – CMS #485 and Physician Orders," revised March 2018, indicated, "Policy Skilled nursing and other home health services will be in accordance with a Plan of Care based on the patient's diagnosis and assessment of immediate and long range needs and resources. Each Plan of care must be signed and dated by the physician. . . Care and services provided will be provided according to physician orders. . . Drugs, services and treatments are administered by staff only as ordered by physician. . ." 1. Review of P3's "Home Health Certification and Plan of Care" under the "Orders" tab in the electronic medical record (EMR) for the certification period of 11/17/22 to 01/15/23 indicated the home health aide frequency was one time a week for nine weeks. Review of a physician's order under the "Orders" tab for P3 dated 12/01/22 indicated "Home Health Aide for bathing." There was no frequency noted. The order should have indicated the increase in frequency to two times a week. Review of P3's EMR indicated home health aide visits were conducted by Certified Nursing Assistant (CNA) 1 two times a week for the weeks of 11/27/22, 12/04/22, and 12/18/22 (11/29/22, 12/02/22, 12/06/22, 12/09/22, 12/19/22, 12/21/22) with no physician order received to increase the aide frequency. In an interview on 01/10/23 at 11:45 AM, DON stated P3 was supposed to be seen two times a week and then once a week, but an order with that frequency wasn't written. DON stated the order written on 12/01/22 didn't include a frequency for the aide visits. DON confirmed there was no documentation in P3's EMR that P3's physician was notified of the change in P3's POC when visits were made twice a week without a physician's order. 2. Review of P4's "Home Health Certification and Plan of Care" under the "Orders" tab in the EMR for the certification period of 12/06/22 to 02/03/23 indicated aide services were not ordered. Review of P4's "Aide Care Plan" under the "HHA" tab in the EMR indicated the aide frequency of "starting week of 12-18-22 1x7wkx" [12/18/22 one time a week times seven week]. Review of P4's EMR indicated a home health aide visit was made by CNA1 on 12/22/22 with no physician order for the visit. There was no documentation in P4's EMR that P4's physician was notified of the change to P4's POC. In an interview on 01/10/23 at 12:00 PM, DON confirmed P4's EMR did not have a physician's order for aide services. DON confirmed there was no documentation that P4's physician was notified of the change in P4's POC.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on policy review, "Quality, Safety & Oversight (QSO) memo 23-02,” and interview, the home health agency (HHA) failed to ensure the agency's COVID-19 vaccination policy contained all the required content. This deficient practice had the potential to affect the current 60 patients, all current staff, any future patient admitted to the HHA for home health services, and any future staff employed or contracted to provide home health services. 1.Review of the agency policy titled, "Employee COVID-19 Vaccinations," updated 12/12/22, indicated ". . . The facility will ensure that all eligible employees are fully vaccinated (CMS [Centers for Medicare and Medicaid Services] term) or up to date (CDC [Centers for Disease Control and Prevention] term) against COVID-19, unless religious or medical exemptions are granted as per CMS guided timeframes. . . 4. The facility will ensure that all staff )except for staff who have pending requests for, or who have been granted exemptions to the vaccination requirements, or staff for whom COVID-19 vaccination must be temporarily delayed, as per CDC recommendations, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the facility and/or its residents. (Define your facility's process to ensure compliance) 5. The facility will ensure that all staff (except for staff who have been granted exemptions to the vaccination requirements, or those staff for whom COVID-19 must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) are fully vaccinated (CMS term) or up to date (CDC term) for COVID-19. (Define your facility's process to ensure compliance) . . . 9. The facility will implement additional precautions to mitigate the transmission and spread of COVID-19 for all staff who are not fully vaccinated (i.e. [that is], not completed primary series yet, has a pending or granted religious/medical exemption, or vaccine is delayed for a certain reason, etc. [and so on]) (CMS term) or up to date (CDC term) for COVID-19. (Specify for your facility the precautions/mitigation actions to be taken, i.e., masking, social distancing, reassignment, testing, use on N95 or higher-level respirator, etc.) . . . 12. The facility will establish contingency plans in the event that staff have indicated that they will not get vaccinated and do not qualify for an exemption or staff who are not fully vaccinated (CMS term) or up to date (CDC term) due to an exemption or temporary delay in vaccination. (Specify plan, i.e., deadlines for vaccination, consequences for not getting vaccinated, obtaining temporary vaccinated staff until permanent vaccinated replacements can be found, etc.) . . . 14. The facility will track and securely document the vaccination status of each staff member (current and as new employees are onboarded), to include: (Specify how this information will be tracked, obtained, and documented. . ." The agency policy, "Employee COVID-19 Vaccinations" did not include the following content required by "QSO-23-02-ALL Revised Guidance for Staff Vaccination Requirements": a. A process for ensuring the implementation of additional precautions, intended to mitigate the transmission, and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19 b. A process for tracking and securely documenting the COVID-19 vaccination status of all staff c. A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC d. A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements e. A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (1) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (2) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA’s COVID-19 vaccination requirements for staff based on the recognized clinical contraindications f. A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment g. Contingency plans for staff who are not fully vaccinated for COVID-19. In an interview on 01/11/23 at 10:25 AM, Chief Executive Officer confirmed the HHA's policy did not include the processes for COVID-19 vaccination as required by " QSO-23-02-ALL Revised Guidance for Staff Vaccination Requirements."

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on patient medical record reviews, policy reviews, and interviews, the home health agency (HHA) failed to ensure services were provided as ordered by the physician for one (Patient (P) 5) of seven patient records reviewed. This deficient practice had the potential to affect the current 60 patients receiving services from the HHA and any future patient admitted for home health services. Review of the agency policy titled, "Plan of Care – CMS #485 and Physician Orders," revised March 2018, indicated "Policy Skilled nursing and other home health services will be in accordance with a Plan of Care based on the patient's diagnosis and assessment of immediate and long range needs and resources. Each Plan of care must be signed and dated by the physician. . . Each patient must receive the home health services that are written in an individualized plan of care. . . All patient care orders, including verbal orders, must be recorded in the plan of care. . . Consultation with the physician on any modification in the Plan of Care will be documented and the physician's signature obtained according to state law and/or prior to billing as required. . . Care and services provided will be provided according to physician orders. . . Drugs, services and treatments are administered by staff only as ordered by physician. . ." Review of P5's "Home Health Certification and Plan of Care" for the certification period of 12/01/22 to 01/29/23 indicated the skilled nurse frequency was one time a week times nine weeks. Review of the skilled nurse visit documentation indicated a skilled nurse visit was not made the week of 12/04/22 (second week of care) as ordered by the physician. There was no documentation in P5's EMR that P5's physician was notified of the change in the POC. In an interview on 01/10/23 at 12:11 PM, DON confirmed no skilled nurse visit was made the week of 12/04/22. DON confirmed there was no documentation in P5's EMR that P5's physician was informed of the missed skilled nurse visit.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on patient medical record reviews, policy review, and interviews, the home health agency (HHA) failed to ensure the staff communicated with the physician when there was a change in the patient's plan of care (POC) for three (Patient (P)3, P4, P5) of seven patient records reviewed. This deficient practice had the potential to affect the current 60 patients receiving services from the HHA and any future patient admitted for home health services. Review of the agency policy titled "Plan of Care – CMS #485 and Physician Orders," revised March 2018, indicated "Policy Skilled nursing and other home health services will be in accordance with a Plan of Care. . . Consultation with the physician on any modification in the Plan of Care will be documented and the physician's signature obtained according to state law and/or prior to billing as required. . ." 1. Review of P3's "Home Health Certification and Plan of Care" under the "Orders" tab in the electronic medical record (EMR) for the certification period of 11/17/22 to 01/15/23 indicated the home health aide frequency was one time a week for nine weeks. Review of P3's EMR indicated home health aide visits were conducted by Certified Nursing Assistant (CNA) 1 two times a week for the weeks of 11/27/22, 12/04/22, and 12/18/22 (11/29/22, 12/02/22, 12/06/22, 12/09/22, 12/19/22, 12/21/22) with no physician order received to increase the aide frequency. In an interview on 01/10/23 at 11:45 AM, DON stated P3 was supposed to be seen two times a week and then once a week, but an order with that frequency wasn't written. DON stated the order written on 12/01/22 didn't include a frequency for the aide visits. DON confirmed there was no documentation in P3's EMR that P3's physician was notified of the change in P3's POC when visits were made twice a week without a physician's order. 2. Review of P4's "Home Health Certification and Plan of Care" under the "Orders" tab in the EMR for the certification period of 12/06/22 to 02/03/23 indicated aide services were not ordered. Review of P4's "Aide Care Plan" indicated the aide frequency of "starting week of 12-18-22 1x7wkx" [12/18/22 one time a week times seven week]. Review of P4's EMR indicated a home health aide visit was made by CNA1 on 12/22/22 with no physician order for the visit. There was no documentation in P4's EMR that P4's physician was notified of the change to P4's POC. In an interview on 01/10/23 at 12:00 PM, DON confirmed P4's EMR did not have a physician's order for aide services. DON confirmed there was no documentation that P4's physician was notified of the change in P4's POC. 3. Review of P5's "Home Health Certification and Plan of Care" under the "Orders" tab in the EMR for the certification period of 12/01/22 to 01/29/23 indicated the skilled nurse frequency was one time a week times nine weeks. Review of the skilled nurse visit documentation under the "Nursing" tab in the EMR indicated a skilled nurse visit was not made the week of 12/04/22 as ordered by the physician. There was no documentation in P5's EMR that P5's physician was notified of the change in the POC. In an interview on 01/10/23 at 12:11 PM, DON confirmed no skilled nurse visit was made the week of 12/04/22. DON confirmed there was no documentation in P5's EMR that P5's physician was informed of the missed skilled nurse visit that changed P5's POC.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on policy review, observation, and interviews, the home health agency (HHA) failed to monitor, manage, and maintain the equipment used to access the web-based electronic medical record (EMR). The use of staff-owned personal computers and cell phones to access the EMR had the potential to compromise personal patient information and could affect all patients receiving services from the HHA and all patients who have received past services. Review of the policy titled "Information Confidentiality, Security and Data Integrity," revised March 2018, indicated the purpose of the policy was to: . . . maintain the security, confidentiality, and integrity of all Agency data and information across all systems (automated and manual). To comply with current federal and state mandates. . . Agency staff and staff under arrangement who carry documents and/or electronic devices containing Protected Health Information (PHI) from patient's homes to the Agency office, or to and from the Agency staff's home creates additional confidentiality/protection concerns with patient records. Staff will observe all defined patient confidentiality policies and HIPAA rules for PHI. . ." The policy did not provide a means of monitoring, managing, and maintaining the equipment used to access the web-based electronic medical record (EMR) with staff using staff-owned personal computers and cell phones. In an interview on 01/09/23 at 9:10 AM, the Director stated some staff use their own personal computers, and some use agency-provided computers/tablets to document patient care in the web-based system. The Director stated the agency provides compensation for the staff's use of their personal cell phones for home health communication with patient physicians. During a visit at the home of Patient (P)7 on 01/10/23 at 9:45 AM, observed Registered Nurse (RN) 1 document P7's assessment findings on a sheet of paper during the visit. In an interview on 01/10/23 at 10:38 AM, RN1 stated he/she documents the visit note in the web-based EMR after the visit on RN1's personal cell phone. RN1 stated he/she is not aware of a system in place for the HHA to check RN1's cell phone for security of confidential patient information. No documentation was presented during the survey of the agency's ability to monitor, manage, and maintain the equipment used to access the web-based EMR by staff who use personal computers and cell phones.